Kids Activity and Nutrition Questionnaire The AZ Health Zone wants to learn about what kids your age eat, and how they are active. This survey asks questions about your food choices and exercise. Your answers will help make the program the best it can be. We will ask you to take the survey at two different times. Each time, it will take you about 20 minutes. Taking part in this survey is up to you. Your choice will not affect your grades in school. Your choice will not affect whether you can do any school or summer activities. If you do not want to answer a question, you can skip it. You can stop taking the survey at any time. No one at school or at home will see your answers. We do not know of any risks or benefits to doing this survey. Please use a pencil to bubble in your answers. Write your first and last name. Put one letter in each box. First Name Last Name
1. How old are you? 8 9 11 12 14 15 5. Yesterday, did you eat any dark or whole grain macaroni, noodles, bread, tortillas, or rice? 10 13 2. What grade are you in? 3rd 5th 7th 4th 6th 8th No. I did not eat any of these foods 3. Are you a boy or girl? Girl Boy 4. Yesterday, did you eat any white macaroni, noodles, bread, tortillas, or rice? Yes. I ate one of these foods 1 time Yes. I ate one of these foods 2 times Yes. I ate one of these foods 3 times Yes. I ate one of these foods 4 times No. I did not eat any of these foods Yes. I ate one of these foods 1 time Yes. I ate one of these foods 2 times Yes. I ate one of these foods 3 times Yes. I ate one of these foods 4 times Yes. I ate one of these foods 5 or more times Yes. I ate one of these foods 5 or more times 6. What type of milk do you drink most of the time? Choose only one. Do not use cap color to pick the type of milk you drink. Whole milk 2% reduced fat milk 1% (low fat) or fat free milk Soy, almond, rice, or other milk I never drink milk. 1
7. Yesterday, did you eat or drink any milk, yogurt, or cheese? You can count flavored milk, soy milk, and drinks made with yogurt. No. I did not eat any of these foods Yes. I had milk, yogurt or cheese 1 time Yes. I had milk, yogurt or cheese 2 times Yes. I had milk, yogurt or cheese 3 times Yes. I had milk, yogurt or cheese 4 times Yes. I had milk, yogurt or cheese 5 or more times 9. Yesterday, did you eat any fruit? You can count all fresh, frozen, canned or dried fruits. Do not count fruit juice. No. I did not eat any fruit. Yes. I ate fruit 1 time Yes. I ate fruit 2 times Yes. I ate fruit 3 times Yes. I ate fruit 4 times Yes. I ate fruit 5 or more times 10. Yesterday did you eat any fish, eggs, nuts or peanut butter? 8. Did you eat any vegetables yesterday? You can count mashed potatoes and beans. Do not count french fries or chips. No. I did not eat any vegetables Yes. I ate vegetables 1 time Yes. I ate vegetables 2 times Yes. I ate vegetables 3 times Yes. I ate vegetables 4 times Yes. I ate vegetables 5 or more times No. I did not eat any of these foods Yes. I ate one of these foods 1 time Yes. I ate one of these foods 2 times Yes. I ate one of these foods 3 times Yes. I ate one of these foods 4 times Yes. I ate one of these foods 5 or more times 2
11. Yesterday, did you drink any regular (not diet) soda, sports drink, juice box, or other sugary drink? Do not count 100% fruit juice. No. I did not drink any of these drinks Yes. I had a drink like this 1 time Yes. I had a drink like this 2 times Yes. I had a drink like this 3 times Yes. I had a drink like this 4 times Yes. I had a drink like this 5 or more times 13. How many hours did you watch TV when you were NOT in school yesterday? I did not watch TV Less than one hour 1 hour 2 hours 3 hours 4 hours 5 hours 6 hours or more 14. How many hours did you use a computer, phone, or tablet or play video games when you were NOT in school yesterday? 12. Yesterday, did you drink any water? No. I did not drink water Yes. I drank water 1 time Yes. I drank water 2 times Yes. I drank water 3 times Yes. I drank water 4 times Yes. I drank water 5 times Yes. I drank water 6 times Yes. I drank water 7 times Yes. I drank water 8 or more times 3 I did not use these things or play video games Less than one hour 1 hour 2 hours 3 hours 4 hours 5 hours 6 hours or more
15. What physical activities did you do last week? Physical activity makes your heart beat fast and makes you breathe hard. It includes PE, basketball, soccer, running around, dancing, other sports, exercise, or similar activities. All of the kids in the pictures above are doing physical activities. BUBBLE IN ALL OF THE DAYS THAT YOU WERE ACTIVE LAST WEEK. I was active before school on these days last week. Do not include team sports. I was active during recess at school on these days last week. I was active during PE at school on these days last week. I was active after school on these days last week. Do not include team sports. I played a team sport on these days last week. I was active during the weekend on these days last week. Saturday Sunday 4
16. How much of your plate at meals should be fruits and vegetables? 18. What type of milk should most kids drink most of the time? Whole milk 2% reduced fat milk None Some About half Most 1% (low fat) or fat free milk, or soy milk with added calcium All 19. How many minutes of physical activity or exercise should most kids get each day? 17. How much of the grains that most kids eat should be made with whole grains? Grains are foods like bread, cereal, rice, and noodles. 15 minutes or less None Some About half Most All 30 minutes 45 minutes 60 minutes (1 hour) 5
20. How do you feel about eating fruit? I really like to eat fruit I kind of like to eat fruit. I don t like to eat fruit. I really don t like to eat fruit. I m not sure if I like to eat fruit. 21. How do you feel about eating vegetables? I really like to eat vegetables. I kind of like to eat vegetables. I don t like to eat vegetables. I really don t like to eat vegetables. I m not sure if I like to eat vegetables. 22. How do you feel about eating foods made with whole grains, like brown rice or dark bread? I really like to eat whole grain foods. I kind of like to eat whole grain foods. I don t like to eat whole grains foods. I really don t like to eat whole grain foods. I m not sure if I like to eat whole grain foods. 23. How do you feel about drinking milk low in fat, like fat free or 1% milk? I really like to drink low fat milk. I kind of like to drink low fat milk. I don t like to drink low fat milk. I really don t like to drink low fat milk. I m not sure if I like to drink low fat milk. 24. How do you feel about having drinks low in sugar, like water or plain white milk? I really like drinks low in sugar. I kind of like drinks low in sugar. I don t like drinks low in sugar. I really don t like drinks low in sugar. I m not sure if I like drinks low in sugar. 25. How do you feel about doing physical activity? I really like to do physical activity. I kind of like to do physical activity. I don t like to do physical activity. I really don t like to do physical activity. I m not sure if I like to do physical activity. 6
Kids Activity and Nutrition Questionnaire That s the END of the survey! Thanks for answering the questions. Information for Adults This material was funded by USDA s Supplemental Nutrition Assistance Program - SNAP through the AZ Health Zone. This institution is an equal opportunity provider. More information about the KAN-Q may be found in the following publication: LeGros TA, Hartz VL, Jacobs LE. Reliability of a Kid s Activity and Nutrition Questionnaire for School-Based SNAP-ED Interventions as Part of a Tiered Development Process. Journal of Nutrition Education and Behavior. 2017; 49:125-129 Contact Information: AZ Health Zone 602-542-1886. January 2018